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My partners newly diagnosed
Apr 25, 2005

Hi there,

I am 25 years old and have been +ve for 3 years and my partner is 28 years old and was recently diagnosed here in Edinburgh, Scotland. Basically his advisor has told him that he's looking at a sero conversion of 3-4 months past, and his VL count is 216,000 and CD4 659.

Clearly the CD4 count is acceptable, but the VL is not. I am well aware that sometimes a newly diagnosed individual might initially have a high count which might drop off, but the other variable is that this is a aggressive strain which will only continue to increase. My experience is that most people newly diagnosed are not hammered with a high count such as this, I know it varies from person to person, and surely some people have well exceeded a million VL on first diagnosis, but I think a doctor advising someone with a viral load of 216,000 to check back in nearly 3 months, and that gingerly, is rather careless ?

I have in my years seen many people be placed on treatment straight away that have had so called unacceptably high VL's on first test, some have not, but will we be told 10 years down the road that the way we are handling new diagnosis's has actually been more detrimental to the health than previously thought ? The target is to have the least amount of VL eating away at the Immune system, regardless if one feels fit and normal, so why then would my partner for example not be asked to test again for safe measure in a month for example, what's the pain in airing on the side of caution, versus throwing caution to the wind and investing all one's trust in one so called specialist. Certainly considering how different each country, especially the UK versus the US looks at HIV and affective treatment.

Thanks, DD

Response from Dr. Pierone

Hello and thanks for posting. You are right that this is a high viral load and sometimes these initial high readings come down as partial immunologic control of virus develops. Honestly, we don't know the best course of action for someone recently diagnosed with a high viral load. It comes down to weighing the risks of therapy versus the benefits and we don't have data nearly robust enough to provide a clear answer.

Is it careless to not recheck labs in 3 months in someone newly diagnosed? I would like a retest in about 4 weeks, but this is based on a desire to see how much early variability there is for an individual, not because the information will necessarily change anything. It will take several readings over the next 6 to 12 months to establish a trend in any case.

Is the target to have the least amount of viral load eating away at the immune system regardless of whether the person feels well? If this truly is the target, then everyone with HIV infection should be considered for treatment. But CD4 count, level of viral load, degree of immune activation, potential development of drug resistance, antiretroviral toxicity, medication cost, and patient preferences all enter into the mix.

The treatment guidelines from the British HIV Association do not recommend treatment with CD4 count above 350. The DHHS guidelines state that with CD4 count above 350 with a viral load above 100,000 most experienced HIV clinicians would defer treatment, but some would consider it this leaves the door open for early therapy. Treatment decisions should be reached in a collaborative doctor/patient manner that recognizes the limitations of current data. As you say, 10 years from now we may look back and marvel at some of the decisions we are making now - by then we will have the answers and it will be abundantly clear if the correct approach was "watchful waiting" or "hit early and hard".



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